Application for Employment

Medina Regional Hospital 3100 Ave E Hondo, Texas 78861 (830) 426-7700

Equal access to programs, services and employment is available to all persons. Those applicants requiring reasonable accommodation to the application and/or interview process should notify a representative of the Human Resources Department.

Date of Application:

Your email:

Department(s) applied for:

Position(s) applied for:

Last Name:

First Name:

Middle Name:

Other names you have worked under (maiden, prior marriage, etc.)

Current address

Street:

City:

State:

Zip:

P.O. Box:

City:

State:

Zip:

Previous address

Street:

City:

State:

Zip:

Telephone #

Mobile/Beeper/Other Phone #

Social Security #

If you are under 18, and it is required, can you furnish a work permit?

Yes

No

If no, please explain

Have you ever been employed here before?

Yes

No

Date available for work

Type of employment desired?

Full-Time

Part-Time

Temporary

Are you able to meet the attendance requirements of the position?

Yes

No

Have you been convicted of a crime in the last seven (7) years?

Yes

No

If yes, please explain

CONVICTION WILL NOT NECESSARILY BE A BAR TO EMPLOYMENT, EACH INSTANCE AND EXPLANATION WILL BE CONSIDERED IN RELATION TO THE POSITION FOR WHICH YOU ARE APPLYING

Driver's license number if driving is an essential job function:

State:

Employment History Provide the following information for your past four (4) employers, assignments or volunteer activities, starting with the most recent.

From

To

Employer

Telephone

Job Title

Address

Immediate Supervisor and Title

Summarize the nature of work performed and job responsibilities

Reason for leaving

Hourly rate/salary start $

Per

Final $

Per

From

To

Employer

Telephone

Job Title

Address

Immediate Supervisor and Title

Summarize the nature of work performed and job responsibilities

Reason for leaving

Hourly rate/salary start $

Per

Final $

Per

From

To

Employer

Telephone

Job Title

Address

Immediate Supervisor and Title

Summarize the nature of work performed and job responsibilities

Reason for leaving

Hourly rate/salary start $

Per

Final $

Per

From

To

Employer

Telephone

Job Title

Address

Immediate Supervisor and Title

Summarize the nature of work performed and job responsibilities

Reason for leaving

Hourly rate/salary start $

Per

Final $

Per

Professional Licenses, Certifications and/or Registrations Held

Title		Expiration Date
License #		State(s) held

Title		Expiration Date
License #		State(s) held

Title		Expiration Date
License #		State(s) held

Title		Expiration Date
License #		State(s) held

Skills and Qualifications Summarize any training, licenses, and/or certificates that may qualify you as being able to perform job-related functions in the position for which you are applying

You may attach your resume, certificates or any other documents as part of your application process

Attach Document:		Attach Document:
Attach Document:		Attach Document:
Attach Document:		Attach Document:

Most recent school

School Name:

Phone:

Dates Attended-

Month:

Year:

Street:

City:

State:

Zip:

Degree Title:

Major:

Second most recent school

School Name:

Phone:

Dates Attended-

Month:

Year:

Street:

City:

State:

Zip:

Degree Title:

Major:

References

Name:		Telephone:		Years known:
Name:		Telephone:		Years known:
Name:		Telephone:		Years known:

General Comments:
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Please read the following before clicking the "Submit Application" button below!
I UNDERSTAND THAT IF I AM EMPLOYED, ANY MISREPRESENTATION OR MATERIAL OMISSION MADE BY ME ON THIS APPLICATION WILL BE SUFFICIENT CAUSE FOR CANCELLATION OF THIS APPLICATION OR IMMEDIATE DISCHARGE FROM THE EMPLOYER'S SERVICE, WHENEVER IT IS DISCOVERED. I GIVE THE EMPLOYER THE RIGHT TO CONTACT AND OBTAIN INFORMATION FROM ALL REFERENCES, EMPLOYEES, EDUCATIONAL INSTITUTIONS AND TO OTHERWISE VERIFY THE ACCURACY OF THE INFORMATION CONTAINED IN THIS APPLICATION. I HEREBY RELEASE FROM LIABILITY THE EMPLOYER AND ITS REPRESENTATIVES FOR SEEKING, GATHERING AND USING SUCH INFORMATION AND ALL OTHER PERSONS, CORPORATIONS OR ORGANIZATIONS FOR FURNISHING SUCH INFORMATION. THE EMPLOYER DOES NOT UNLAWFULLY DISCRIMINATE IN EMPLOYMENT AND NO QUESTION ON THIS APPLICATION IS USED FOR THE PURPOSE OF LIMITING OR EXCUSING ANY APPLICANT FROM CONSIDERATION FOR EMPLOYMENT ON A BASIS PROHIBITED BY LOCAL, STATE, OR FEDERAL LAW. THIS APPLICATION IS CURRENT FOR SIX (6) MONTHS. AT THE CONCLUSION OF THIS TIME, IF I HAVE NOT HEARD FROM THE EMPLOYER AND STILL WISH TO BE CONSIDERED FOR EMPLOYMENT, IT WILL BE NECESSARY TO FILL OUT A NEW APPLICATION. IF I AM HIRED, I UNDERSTAND THAT I AM FREE TO RESIGN AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, AND THE EMPLOYER RESERVES THE SAME RIGHT TO TERMINATE MY EMPLOYMENT AT ANY TIME, WITH OR WITHOUT CAUSE AND WITHOUT PRIOR NOTICE, EXCEPT AS MAY BE REQUIRED BY LAW. THIS APPLICATION DOES NOT CONSTITUTE AN AGREEMENT OR CONTRACT FOR EMPLOYMENT FOR ANY SPECIFIED PERIOD OR DEFINITE DURATION. I UNDERSTAND THAT NO REPRESENTATIVE OF THE EMPLOYER, OTHER THAN AN AUTHORIZED OFFICER HAS THE AUTHORITY TO MAKE ANY ASSURANCES TO THE CONTRARY. I FURTHER UNDERSTAND THAT ANY SUCH ASSURANCES MUST BE IN WRITING AND SIGNED BY AN AUTHORIZED OFFICER. I UNDERSTAND IT IS THIS COMPANY'S POLICY NOT TO REFUSE TO HIRE A QUALIFIED INDIVIDUAL WITH A DISABILITY BECAUSE OF THAT PERSON'S NEED FOR REASONABLE ACCOMMODATION AS REQUIRED BY THE ADA. I ALSO UNDERSTAND THAT IF I AM HIRED, I WILL BE REQUIRED TO PROVIDE PROOF OF IDENTITY AND LEGAL WORK AUTHORIZATION.
By clicking on the Submit Application button, I agree that I have read and understand the above, and hereby certify that the facts I have provided in my employment application are true and complete and seek employment under these conditions.

MEDINA REGIONAL HOSPITAL 3100 Avenue E • Hondo, TX 78861 Phone: (830) 426-7700 • Phone: (830) 741-4677 Toll Free: 800-895-7851